Fungal nail infections, also known as dermatophytic onychomycosis or tinea unguium, occur when a fungus spreads from the skin to the keratin in the nails.

Most fungal nail conditions are found in toenails and occur as a result of an infection by the same fungus that causes athlete’s foot (dermatophyte fungi). However, they can also be caused by yeasts known as candida.

Fungal nail infections can take some time to resolve. There are a number of treatments available, although oral tablets are thought to be the most effective. Traditionally terbinafine, an oral medication, is prescribed once-a-day for several weeks or even months. However, research has shown that it can also be prescribed following a ‘pulsed’ method to produce efficient results.

Here we will look to answer the following questions:

  1. Why do fungal nail infections develop?
  2. What treatment is used for fungal nail infections?
  3. What is pulsed therapy?
  4. What is continuous treatment?
  5. Which method of treatment should I follow? 
  6. Can fungal nail infections resolve on their own?

Why do fungal nail infections develop?

Fungal nail infections can occur for a number of reasons. The majority of infections develop in toenails because the environment created by certain types of footwear can encourage fungi to flourish.

Fungi thrive in moist, warm and dark environments. Hot weather during the summer months and the tendency to wear open footwear can leave people more at risk of developing a fungal infection, especially if they use public showers where fungi can transfer from person to person.

What treatment is used for fungal nail infections?

There are several different types of treatment used to resolve fungal nail infections, including oral tablets and topical antifungals. Antifungal treatments can take a long time to produce a result, potentially close to a year, and they often rely on the patient adhering to a course of treatment over a long period of time.

One form of treatment that may better suit the lifestyle of some patients is pulsed oral therapy.

There have been several studies into pulsed therapy for the administration of terbinafine medications in fungal nail infections. The results have shown that pulsed therapy is at least as effective as continuous treatment and it can be more cost effective and convenient for the patient.

What is pulsed therapy?

Pulsed therapy refers to a particular method of treatment whereby medication is administered, usually in a large dose, in an intermittent manner.

For the treatment of fungal nail infections a 500mg dose of terbinafine is prescribed daily for one week. A three week gap is observed before another 500mg of terbinafine is commenced for another seven day period. This course is continued until three week-long ‘pulses’ of terbinafine are completed.

Studies have shown that this method of treatment can be as effective as continuous treatment. A pulsed course of medication may better suit some patients because they do not have to remember to take the treatment every day over a long period of time.

However, it is important to note that this method of treatment is prescribed ‘off-label’ by doctors. This means that terbinafine is unlicensed when it is prescribed in a pulsed application method. Terbinafine holds a license for continuous treatment.

What is continuous treatment?

Continuous treatment is usually a smaller dose of the drug that is administered across a longer period of time.

When treating fungal nail infections a 250mg dose of terbinafine can be prescribed daily for between 6 weeks and three months for fingernails and between three to six months for toenails.

This method of treatment may provide patients with results after two months for fingernails and three months for toenails.

Both pulsed therapy and continuous treatment are said to be well tolerated by patients and cause few side effects.

Which method of treatment should I follow?

You can choose to follow either a continuous course of treatment or a pulsed therapy course.

However, as mentioned above the pulsed method is prescribed to patients as ‘off-label’. You should make sure that you understand what unlicensed prescribing means and that you are happy with this before commencing a pulsed course of terbinafine or lamisil.

Will a fungal nail infection resolve if left untreated?

No. However, not everyone with a fungal nail infection will feel that they require treatment. Some infections may go unnoticed as they don’t cause any pain or inconvenience.

Page last reviewed:  20/11/2019